Coccidioidomycosis Skin Testing in a Commercially Insured Population, United States, 2014-20171.

Coccidioidomycosis skin testing appears to be uncommon, based on US health insurance claims data. Patient demographic features were consistent with the approval of the test for adults, but few patients had previous coccidioidomycosis diagnosis codes supporting its use for detecting delayed-type hypersensitivity in those with a history of pulmonary coccidioidomycosis.

Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early Peanut Introduction.

Importance: Early peanut introduction reduces the risk of developing peanut allergy, especially in high-risk infants. Current US recommendations endorse screening but are not cost-effective relative to other international strategies. Objective: To identify scenarios in which current early peanut introduction guidelines would be cost-effective. Design, Setting, and Participants: This simulation/cohort economic evaluation used microsimulations and cohort analyses in a Markov model to evaluate the cost-effectiveness of early peanut introduction with and without peanut skin prick test (SPT) screening in high-risk infants during an 80-year horizon from a societal perspective. Data were analyzed from April to May 2019. Exposures: High-risk infants with early-onset eczema and/or egg allergy underwent early peanut introduction with and without peanut SPT screening (100 000 infants per treatment strategy) using a dichotomous 8-mm SPT cutoff value (stipulated in the current US guideline). Main Outcomes and Measures: Cost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy. Results: In the simulated cohort of 200 000 infants and using the base case during the model horizon, a no-screening approach had lower mean (SD) costs ($13 449 [$38 163] vs $15 279 [$38 995]) and higher mean (SD) gain in QALYs (29.25 [3.28] vs 29.23 [3.30]) vs screening but resulted in more allergic reactions (mean [SD], 1.07 [3.15] vs 1.01 [3.02]), severe allergic reactions (mean [SD], 0.53 [1.66] vs 0.52 [1.62]), and anaphylaxis involving cardiorespiratory compromise (mean [SD], 0.50 [1.59] vs 0.49 [1.47]) per individual. In deterministic SPT sensitivity analyses at base-case sensitivity and specificity rates, screening could be cost-effective at a high disutility rate (the negative effect of a food allergic reaction) (76-148 days of life traded) for an at-home vs in-clinic reaction in combination with high baseline peanut allergy prevalence among infants at high risk for peanut allergy and not yet exposed to peanuts. If an equivalent rate and disutility of accidental and index anaphylaxis was assumed and the 8-mm SPT cutoff had 0.85 sensitivity and 0.98 specificity, screening was cost-effective at a peanut allergy prevalence of 36%. Conclusions and Relevance: The results of this study suggest that the current screening approach to early peanut introduction could be cost-effective at a particular health utility for an in-clinic reaction, SPT sensitivity and specificity, and high baseline peanut allergy prevalence among high-risk infants. However, such conditions are unlikely to be plausible to realistically achieve. Further research is needed to define the health state utility associated with reaction location.

Has the DRG system impacted on inpatient allergy care in university dermatology departments in Germany?

BACKGROUND: Diagnostic provocation tests (ICD Z01.5) have a low cost weight in the German DRG system. We aimed at investigating a possible economic impact on the number of provocation tests in German university medical centers (UMC) for dermatology. METHODS: We review quality records of 35 German UMC for 2008 and 2010 (ICD Z01.5, total number of patients as well as priority ranking). RESULTS: 33/35 hospitals gave full data for both years including the ten most frequent diagnoses. Between 2008 and 2010, total number of patients treated increased in 23/33 (70 %) UMC, those with ICD Z01.5 only in 11/24 (46 %) UMC with full data. In 2008, the ICD Z01.5 was in the top ten list of main diagnoses in 29/33 (88 %) hospitals, in 2010 in 25/33 (76 %); also, priority ranking tended to decrease. In contrast, total number of ICD Z01.5 in Germany tended to increase slightly. CONCLUSIONS: We noticed a tendency for decreasing numbers of provocation tests being performed in dermatological UMC in Germany. As there is no evidence for a decreasing number of patients suffering from allergies, one may speculate about a shift to non-university departments due to an economic impact.

Tuberculosis screening of travelers to higher-incidence countries: a cost-effectiveness analysis.

BACKGROUND: Travelers to countries with high tuberculosis incidence can acquire infection during travel. We sought to compare four screening interventions for travelers from low-incidence countries, who visit countries with varying tuberculosis incidence. METHODS: Decision analysis model: We considered hypothetical cohorts of 1,000 travelers, 21 years old, visiting Mexico, the Dominican Republic, or Haiti for three months. Travelers departed from and returned to the United States or Canada; they were born in the United States, Canada, or the destination countries. The time horizon was 20 years, with 3% annual discounting of future costs and outcomes. The analysis was conducted from the health care system perspective. Screening involved tuberculin skin testing (post-travel in three strategies, with baseline pre-travel tests in two), or chest radiography post-travel (one strategy). Returning travelers with tuberculin conversion (one strategy) or other evidence of latent tuberculosis (three strategies) were offered treatment. The main outcome was cost (in 2005 US dollars) per tuberculosis case prevented. RESULTS: For all travelers, a single post-trip tuberculin test was most cost-effective. The associated cost estimate per case prevented ranged from $21,406 for Haitian-born travelers to Haiti, to $161,196 for US-born travelers to Mexico. In all sensitivity analyses, the single post-trip tuberculin test remained most cost-effective. For US-born travelers to Haiti, this strategy was associated with cost savings for trips over 22 months. Screening was more cost-effective with increasing trip duration and infection risk, and less so with poorer treatment adherence. CONCLUSION: A single post-trip tuberculin skin test was the most cost-effective strategy considered, for travelers from the United States or Canada. The analysis did not evaluate the use of interferon-gamma release assays, which would be most relevant for travelers who received BCG vaccination after infancy, as in many European countries. Screening decisions should reflect duration of travel, tuberculosis incidence, and commitment to treat latent infection.

Contribution of residential exposures to asthma in us children and adolescents.

CONTEXT: Residential exposures are recognized risk factors for asthma, but the relative contribution of specific indoor allergens and their overall contribution to asthma among older children and adolescents in the United States are unknown. OBJECTIVE: To estimate the relative contributions, population-attributable risks, and costs of residential risk factors for doctor-diagnosed asthma. Design. Nationally representative, cross-sectional survey conducted from 1988 to 1994. SETTING AND PARTICIPANTS: A total of 5384 children who were 6 to 16 years old and participated in the National Health and Nutrition Examination Survey III, a survey of the health and nutritional status of children and adults in the United States. MAIN OUTCOME MEASURE: Doctor-diagnosed asthma, as reported by the parent. RESULTS: Five hundred three of 5384 children and adolescents (11.4%) had doctor-diagnosed asthma. After adjusting for age, gender, race, urban status, region of country, educational attainment of the head of household, and poverty, predictors of doctor-diagnosed asthma included a history of allergy to a pet (odds ratio [OR: 2.4; 95% confidence interval [CI]: 1.7, 3.3), presence of a pet in the household (OR: 1.5; 95% CI: 1.1, 2.1), and immediate hypersensitivity to dust mite (OR: 1.5; 95% CI: 1.05, 2.0), Alternaria (OR: 1.9; 95% CI: 1.3, 2.8), and cockroach allergens (OR: 1.4; CI: 1.04, 1.9). Family history of atopy (OR: 1.7; 95% CI: 1.1, 2.7) and diagnosis of allergic rhinitis (OR: 2.1; CI: 1.1, 3.7) were also predictors for asthma. The population-attributable risk of having 1 or more residential exposures associated with doctor-diagnosed asthma was 44.4% (95% CI: 29-60), or an estimated 2 million excess cases. The attributable cost of asthma resulting from residential exposures was $405 million (95% CI: $264-$547 million) annually. CONCLUSIONS: The elimination of identified residential exposures, if causally associated with asthma, would result in a 44% decline in doctor-diagnosed asthma among older children and adolescents in the United States.

Likelihood ratios and Fagan's nomogram: valuable but underrated tools for in vitro latex sensitization assessment.

The relevance of latex allergy has greatly increased in the last decade especially in health workers and in children with spina bifida. Serological testing has been proposed in the diagnosis since history can be inconclusive and skin and provocative testing can induce severe adverse reactions. We evaluated positive likelihood ratios (LRpos) and the Fagan's nomogram in the diagnosis of latex allergy. Thirty patients with positive clinical history, who showed positive results in the skin prick test and in glove-exposure test were compared to 36 blood donors with negative clinical history, who showed negative results in the skin prick test and in glove-exposure test. LRpos was calculated at four different cutoff concentrations of IgE specific to latex measured with a totally automated analyzer. LRs appear better compared to the traditional classes in the reporting of IgE and, coupled with the Fagan's nomogram which allows the calculation of post-test probability, could improve laboratory testing in latex allergy.

Intraepithelial mast cells in allergic and nonallergic asthma. Assessment using bronchial brushings.

Mast cell mediators are known to contribute to the pathogenesis of asthma. There is some disagreement concerning the numbers of mast cells in asthmatic mucosa. In this study a standardized bronchial brush technique was developed and used to assess intraepithelial mast cells and other inflammatory cells in allergic and nonallergic asthmatic and nonasthmatic subjects. A total of 10 nonasthmatic (5 allergic) and 13 asthmatic (8 allergic) subjects with stable controlled asthma treated with beta-agonist only were assessed by history, spirometry, allergy prick tests, and methacholine airway responsiveness. During fiberoptic bronchoscopy, bronchoalveolar lavage (BAL) was performed from the middle lobe and standardized bronchial brushings were taken from the lingula and left lower lobe bronchi. Quantitative cell counts were performed blind to the clinical characteristics of the subjects. The average total cell recovery from the brushings was 1.04 (SEM 0.09) x 10(6) ml, with a cell viability of 64% (5.3%). Reproducible total cell and mast cell counts were obtained from brushings taken from two lobar bronchi (ICC 0.86). Mast cells were significantly elevated in asthmatic compared with nonasthmatic subjects (1.5 +/- 0.34 versus 0.15 +/- 0.06%). Allergic asthmatic subjects had the greatest numbers of mast cells (1.86 +/- 0.48%); however, the numbers present in brushings from nonallergic asthmatic subjects were also increased (1.03 +/- 0.45%). The mast cells had the staining characteristics of mucosal mast cells, with formalin-blockable metachromatic staining and positive staining for tryptase. Both asthmatic groups also had elevated BAL eosinophils, and neutrophils were elevated in nonallergic asthmatic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Occupational asthma: fate and management after the diagnosis.

The clinical and socio-professional fate of subjects with occupational asthma is not univocal. We re-examined twenty-nine subjects diagnosed in our center as suffering from this disease an average 14 months, SE 1.54 after the diagnosis. At the follow-up examination each patient underwent interview, spirometry and methacholine challenge, 18 patients (group A) had ceased exposure to the sensitizing agent but among them only 7 had been relocated in another area of the plant, the others had resigned or retired. The other patients had not changed workplace, 7 (group B) having had intermittent exposure to the offending agent and 4 (group C) having continued to be exposed daily. At the follow-up examination only 9 patients were asymptomatic, each of them belonging to group A, whereas in the other 9 of the same group symptoms persisted, although reduced. In group B and C all patients were still symptomatic and required pharmacologic treatment. Within group A patients who became asymptomatic had shorter duration of symptoms before diagnosis (12.9 months, SE 6.4 vs 23.9, SE 9.7), higher FEV-1 (96.1, SE 6.7 vs 86.9, SE 5.6) and PD20FEV-1 (1773.4 micrograms, SE 590 vs 730.8, SE 295) at the time of the diagnosis and showed a significant (p < 0.01) increase in FEV-1 (from 96.1, SE 6.2 to 101.6, SE 5.5) and a tendency to decrease in bronchial reactivity to methacholine at the follow-up examination. At the time of the follow-up examination only 5 out of 29 patients (17.2%) had been contacted by the compensation board.(ABSTRACT TRUNCATED AT 250 WORDS)

Reactividad cutánea a periplaneta americana y blatella germánicaa en pacientes asmáticos / Cutaneous reactivity to periplaneta american and blattella germanic in asthmatic patients

En los últimos años numerosas investigaciones han encontrado una fuerte asociación entre alérgenos del interior de las viviendas y asma. Estudios de sensibilidad cutánea, determinaciones de IgE sérica específica, test de provocación bronquial, estudios en asmáticos que acuden a salas de emergencias y del efecto del control del medio ambiente han vinculado éstos alérgenos y asma. Dentro de este grupo de alérgenos, los provenientes de las cucarachas (CRa) han merecido intensos estudios que han podido asociar la severidad clínica, el uso de esteroides, las visitas a salas de emergencias por asma y, especialmente, la condición socio-económica con la sensibilidad a cucarachas. Este estudio fue realizado a los efectos de establecer la prevalencia de sensibilidad cutánea a extractos de Periplaneta americana (Pa) y Blatella germánica (Bg) en un grupo de asmáticos adultos. Se efectuaron pruebas cutáneas por prick test en 49 personas asmáticas con una edad media de 42,1 años de los cuales 15 varones y 34 mujeres. Todos los pacientes tenían seguridad social. Se utilizaron además alérgenos de ácaros (6 especies), polenes, hongos y de animales domésticos. La positividad general, por lo menos un alérgenos positivo (>3mm), fue del 89,8 por ciento, siendo los ácaros los más frecuentes inductores de positividades (42/49,85,7 por ciento). En 23/49 se hallaron positividades a CRa (46,9 por ciento) siendo Pa la más prevalente (38,7 por ciento). Siempre hubo concordancia entre positividades a CRa y a ácaros y en ninguna ocasión hallamos una prueba positiva a CRa como única sensibilidad. El promedio de edad fue mayor entre los CRa (+) que en los pacientes CRa (-), 44,5 vs. 34,6 años, pero no observamos diferencias en cuanto al sexo. Este estudio muestra la alta prevalencia de sensibilidad a extractos de cucarachas y sugiere la necesidad de incorporarlos a la bateria habitual de test cutáneos